Insider Info Worksheet
Intake Activity Confidential & Safe Space
INSIDER INFO
Welcome! This worksheet belongs to you. Draw, write, and share what feels right.
Name:
Date:
Quick Stats
My Preferred Nickname
Animal that matches my energy today
A word that describes me best
Behind the Headphones
Draw or Write
What is a song, sound, podcast, or game track you could listen to on repeat? Draw the album cover or jot down some favorites below.
Design or list your soundtrack here...
My Interest Blueprint
Safe Spot Where I go when I need to feel cozy/calm:
Boredom Buster My absolute favorite thing to do when bored:
Hidden Skill Something I'm secretly or openly great at:
Ideal Weekend One activity or thing that makes my weekend best:
School Vibes Radar
How does each part of school feel for you? Check one!
1 Classwork & Academics
Hard/Stressful 😟 Just Okay 😐 Fun/Love It 🙂
2 Making & Keeping Friends
Lonely/Tough 😟 Sometimes Hard 😐 Awesome 🙂
3 Hallways, Lunch, & Recess
Too Loud/Wild 😟 Standard Day 😐 Best Part 🙂
First Connection Intake Kit Page 1 of 2
Self-Awareness Inside My Mind & Body
MY EMOTION MATRIX
Let's look at how emotions show up for you and what tools help you control them.
Part Two of the Intake We're in this together!
Body Signals
When I get super stressed, angry, or overwhelmed, my body reacts by:
Tight shoulders/neck Fast heartbeat Butterflies in stomach Clenched hands/fists Heavy or fuzzy head
💡 Our bodies alert us before our brain does!
The Coping Toolbelt
Check your favorites
Which of these help you recalibrate when you're overwhelmed? (Or draw/write your own unique one!)
Deep Breathing Box breathing or 4-7-8 counts
Creative Release Drawing, playing music, writing
Physical Reset Squeezing a stress ball or walking
My Secret Tool
Write yours here...
My Anchor Circle
Identify people (and pets!) in your life who make you feel safe, heard, and anchored.
At School
Teacher, counselor, peer...
At Home
Parent, sibling, guardian...
Other Anchors
Pet, coach, program leader...
The Deep Dive Note
One thing I really want you to know about my world or my life is...
Write or doodle your thought here...
First Connection Intake Kit Page 2 of 2
Counselor Playbook Guide
Facilitation Guide Clinical Practice Tool
Counselor Playbook: First Connection
Strategic protocol for decoding the 5th-Grade Insider Info Worksheet during initial intake.
Grade 5 Intake
Recommended Intake Session Flow (35-45 Min)
0-5 Mins Warm Welcome Establish rapport, define confidentiality parameters.
5-20 Mins Page 1 Completion Focus on hobbies, playlist, school vibes.
20-35 Mins Page 2 Assessment Process somatic signals, coping tools & supports.
35-40 Mins Wrap & Exit Define safety plan, secure agreement, select token.
Therapeutic Interpretation Guide
Behind the Headphones
Clinical Focus: Assesses auditory regulation patterns, isolation habits, and cultural self-identification. Ask: "Does this music help you block things out, pump you up, or match how you feel?"
School Vibes Radar
Clinical Focus: Diagnostic scan of peer dynamics, academic self-efficacy, and transition safety. Pay attention to checkmarks next to "Too Loud/Wild" (sensory overwhelm) or "Lonely/Tough" (isolation).
Somatic Body Signals
Clinical Focus: Highlights psycho-somatic symptoms of anxiety and autonomic activation. Helps student link physical responses to situations, preventing somatic conversions of emotional stress.
Anchor Circle
Clinical Focus: Network analysis. Identify external resources and isolate attachment vulnerabilities (e.g., leaving "At School" blank suggests urgent social-emotional connection needs).
Observational Checklist
- ✔ Aversive/Avoidant Behaviors: Direct refusal of specific blocks (particularly somatic signals).
- ✔ Fine-Motor Regulation: Heavy pencil pressure (rigidity/anger) vs light/hesitant strokes (anxiety/withdrawn).
- ✔ Defense Mechanisms: Over-reliance on humor, excessive formatting, or superficial answers in critical areas.
- ✔ Affect Concordance: Does the physical affect match the selected emoji/mood options?
Strategic Prompts
On Safety: "I noticed you put your bedroom as your Safe Spot. What makes that room feel peaceful for you?"
On Somatic Signals: "When your stomach gets butterflies, what do you usually do? How can we catch those butterflies earlier?"
On Support: